Friday, August 10, 2012

Paucis Verbis: Overanticoagulation and supratherapeutic INR

I find it amazing that I know more non-emergency physicians virtually in the social media world rather than in person. Primarily through Twitter, I follow and am followed by medical educators from various specialties. If you haven't joined Twitter yet, I think it might be time. There is a whole world of collaboration and conversation going on in this virtual community, which crosses specialties and geography.


Last week, Dr. Javier Benítez (@jvrbntz) was tweeting a Question of the Day, referencing a 2010 Paucis Verbis card on overanticoagulation, which was based on the 2008 American College of Chest Physicians (ACCP) guidelines. About 8 minutes after I retweeted his question, Dr. Roy Arnold (@cholerajoe), a pulmonary/critical care physician kindly informed me that the 2012 ACCP guidelines have been out since February.

So this PV card is replacing the 2010 card with revised recommendations. To more in-depth discussion, definitely take a look at Dr. Scott Weingart's great podcast over at EMCrit. He helps to clarify holes which the 2012 ACCP guidelines don't really address such as:

  • Question: What if the patient is minorly bleeding with a high INR? 
  • Answer: Oral vitamin K and 15 mL/kg FFP
  • Question: What if you only have the 3-factor PCC (factors II, IX, X) and not the recommended 4-factor PCC (factors II, IX, X plus factor VII)? The U.S. primarily has the 3-factor PCC. At my institution, we have bebulin.  
  • Answer: If PCC is indicated, add recombinant factor VIIa or FFP to the 3-factor PCC to cover for factor VII.
2008 ACCP guidelines



New 2012 ACCP guidelines and pearls


Feel free to download this card and print on a 4'' x 6'' index card.

See other Paucis Verbis cards.

References
Holbrook A, et al; American College of Chest Physicians. Evidence-based management of anticoagulant therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012 Feb;141(2
Suppl):e152S-84S. Pubmed .
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4 comments:

  1. That was a snarky response by Dr. Arnold.

    ReplyDelete
    Replies

    1. Ha, no worries. Sometimes humor doesn't translate as well digitally. If he hadn't tweeted me, I wouldn't have known that there was an update.

      Delete

  2. To matters more complicated... For people who want to look at the primary literature regarding warfarin reversal with PCC, one pitfall to be aware of is that, worldwide, there are over a dozen different factor concentrate products with different numbers and concentrations of factors. Just makes translation of some studies that much more difficult.

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    Replies

    1. Argh, I know. That totally is frustrating. I know that U.S. PCC's are 3-factor (lacking significant factor VII) and international are usually 4-factor. The 4 factors are II, VII, IX, X. So for me, in the U.S., I use PCC + FFP to cover for factor VII. See Scott Weingart's great podcast:

      http://blog.ercast.org/2012/06/anticoagulation-reversal/

      Delete

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